A NOTE ON DISEASES CLINICALLY PRESENTING AS DESQUAMATIVE GINGIVITIS

DISEASES CLINICALLY PRESENTING AS DESQUAMATIVE GINGIVITIS

Lichen Planus

Lichen planus is a relatively common, chronic, dermatosis characterized by the presence of cutaneous   violaceous papules that may coalesce to form plaques. The current evidence suggests that lichen planus is an immunologically mediated mucocutaneous disorder where host T lymphocytes play a central role . Although the oral cavity may present lichen planus lesions with a distinct clinical configuration and distribution, the clinical presentation sometimes may simulate other mucocutaneous disorders. Therefore a clinical diagnosis of oral lichen planus should be accompanied by a broad differential diagnosis. Numerous epidemiologic studies have shown that oral lichen planus presents in 0.1% to 4% of the population." The majority of patients with oral lichen planus are middle-aged and older females with a 2:1 ratio of females to males. Although possible, children are rarely affected. In a dental setting, cutaneous lichen planus is observed in about one third of the patients diagnosed with oral lichen planus.  In contrast, two thirds of patients seen in dermatologic clinics exhibit oral lichen planus.

Oral Lesions

Although there are several clinical forms of oral lichen planus (reticular, patch, atrophic, erosive and bullous), the most common are the reticular and erosive subtypes. The typical reticular lesions are asymptomatic, bilateral, and consist of interlacing white lines on the posterior region of the buccal mucosa. The lateral border and dorsum of the tongue, hard palate, alveolar ridge, and gingiva may also be affected. In addition, it is not unusual for the reticular lesions to have an erythematous background, a feature that is associated with the coexistence of candidiasis. Oral lichen planus lesions follow a chronic course and have alternating, unpredictable periods of quiescence and flares.

The erosive subtype of lichen planus is often associated with pain and clinically manifests as atrophic, erythematous areas. Fine white radiating striations are observed bordering the atrophic zones. These areas may be sensitive to heat, acid, and spicy foods.

Gingival Lesions

Up to 10% of patients with oral lichen planus have lesions restricted to the gingival tissue that may occur as one or more types of four distinctive patterns:

1. Keratotic lesions. These raised white lesions may present as groups of individual papules, linear or reticulate lesions, or plaquelike configurations.

2. Erosive or ulcerative lesions. These extensive erythematous areas with a patchy distribution may present as focal or diffuse hemorrhagic areas. These lesions are exacerbated by slight trauma (e.g., toothbrushing).

3. Vesicular or bullous lesions. These raised, fluid-filled lesions are uncommon and short lived on the gingiva, quickly rupturing and leaving an ulceration.

4. Atrophic lesions. Atrophy of the gingival tissues with ensuing epithelial thinning results in erythema confined to the gingiva.

Histopathologic, Direct, and Indirect Immunofluorescence Findings in Selected Conditions That May Present Clinically as Desquamative Gingivitis
Disease	Histopathology	Direct Immunofluorescence		Indirect Immunofluorescence
		Biopsy Perilesional Mucosa	Biopsy Uninvolved Mucosa
Pemphigus	Intraepithelial clefting above the basal cell layer. The basal cells have a characteristic "tombstone" appear- ance. Acantholysis is present.	Intercellular deposits in epithelium; IgG in all cases, C3 in most cases.	Same as perilesional mucosa.	Intercellular (IgG) anti- bodies in >90% of cases.
Cicatricial pemphigoid	Subepithelial clefting with epithelial separation from the underlying lamina propria, leaving an intact basal layer.	Linear deposits of C3, with or without IgG at the basement membrane zone in almost all cases.	Same as perilesional mucosa.	Basement membrane zone (IgG) antibodies in 10% of cases.
Bullous pemphigoid	Subepithelial clefting with epithelial separa- tion from the under- lying lamina propria, leaving an intact basal layer.	Linear deposits of C3, with or without IgG at the basement membrane zone in almost all cases.	Same as perilesional mucosa.	Basement membrane zone (IgG) antibodies in 40% to 70% of cases.
Epidermolysis bullosa acquisita	Similar to bullous and cicatricial pemphigoid.	Linear deposits of IgG and C3 at the Basement membrane zone in almost all cases.	Same as perilesional mucosa.	Basement membrane zone (IgG) antibodies in 25% of cases.
Lichen planus	Hyperkeratosis, hydropic degeneration of the basal layer, "saw-toothed" rete pegs. The lamina propria exhibits a dense, band- like infiltrate primarily of T lymphocytes. Colloid bodies are present.	Fibrilar deposits of fibrin at the dermal-epiderma junction.	Negative	Negative
Chronic ulcerative stomatitis	Similar to erosive lichen planus (hype rkeratosis, acanthosis, basal cell layer liquefaction, sub- epithelial clefting, and lympho-histiocytic chronic infiltrate in a bandlike configuration.	IgG deposits in nuclei of basal layer epithelial cells.	Same as perilesional mucosa.	ANA specific for basal cells of stratified squamous epithelium.
Linear IgA disease	Similar to erosive lichen planus.	Linear deposits of IgA at the basement membrane zone.	Same as perilesional mucosa.	IgA basement membrane zone (IgA) antibodies in 30% of cases.
Dermatitis herpetiformis	Collection of neutro- phils, eosinophils, and fibrin in connective tissue papillae.	IgA deposits in dermal papillae in 85% of cases.	IgA deposits in dermal papillae in 100% of cases.	IgA endomysial antibodies in 70% of cases, gliadin antibodies in 30% of cases.
Systemic lupus erythematosus	Hyperkeratosis, basal cell degeneration, epithelial atrophy, and perivascular inflammation.	I g (G or M), with or without C3 deposits at dermal-epidermal junction.	Same as perilesional mucosa.	ANA in more than 95% of cases, DNA and ENA antibodies in more than 50% of cases.
Chronic cutaneous lupus erythematosus	Hyperkeratosis, basal cell degeneration, epithelial atrophy, and perivascular inflammation.	Ig (G or M), with or without C3 deposits at dermal-epidermal junction.	Negative	Usually negative
Subacute lupus erythematosus	Less inflammatory cell infiltrate than systemic and chronic cutaneous lupus erythematosus but with similar microscopic features.	Ig (G or M), with or without C3 deposits at dermal-epidermal junction in 60% of cases; granular IgG deposits in basal cell cytoplasm in 30% of cases.	Same as perilesional mucosa.	ANA in 60% to 90%, SS-A(Ro) in 80%, RF in 30%, and RNP in 10% of cases.

Gingivitis: clinical features. A, Localized, diffuse, intensely red area facial of tooth #7 and dark pink marginal changes in the remaining anterior teeth. B, Generalized papillary gingivitis. C, Generalized marginal inflammatory lesion. D, Generalized diffuse inflammatory lesion. E, Papillary gingival enlargement. F, Different degrees of recession. Recession is slight in teeth #26 and 29 and marked in #27 and 28.

Note the irregular contours of the gingiva in #28 and the lack of attached gingiva in #27. G, Insertion of a probe into the gingival sulcus.

Note the lack of stippling, the slightly rolled margins, and the dark red color. H, Bleeding appears about 30 seconds after probing.

A, Necrotizing ulcerative gingivitis: typical punched out interdental papilla between mandibular canine and lateral incisor. B, Necrotizing ulcerative gingivitis: typical lesions with progressive tissue destruction. C, Necrotizing ulcerative gingivitis: typical lesions with spontaneous hemorrhage. D, Necrotizing ulcerative gingivitis: typical lesions producing irregular gingival contour. E, Primary herpetic gingivostomatitis: typical diffuse erythema. F, Primary herpetic gingivostomatitis: vesicles on the gingiva.

Erosive lichen planus presenting as desquamative gingivitis. The gingival tissues are erythematous, ulcerated, and painful.

Gingival mucous membrane pemphigoid. Lesions of cicatricial pemphigoid confined to the gingival tissues, producing a typical desquamative gingivitis appearance.

Pemphigus vulgaris of the gingiva. Clinical appearance of a patient with pemphigus vulgaris presenting oral lesions confined to the gingiva. The clinical diagnosis was consistent with desquamative gingivitis.

Pemphigus vulgaris of the oral cavity. Multiple and coalescent areas of ulceration covered by necrotic epithelium. This patient presented with large ulcers in the labial mucosa, tongue, and soft palate.

Chronic ulcerative stomatitis. Erythema and ulceration of the gingiva consistent with a clinical diagnosis of desquamative gingivitis.

Linear IgA. Intense erythema and ulceration of the gingiva consistent with desquamative gingivitis.

Lupus erythematosus of the oral cavity presenting as desquamative gingivitis. Intense erythema with ulceration bordered by white radial lines.

Plasma cell gingivitis. The gingiva presents a band of moderate to severe inflammation reminiscent of desquamative gingivitis.

Graft versus host disease in a recipient of an allogenic bone marrow transplant. The maxillary gingiva exhibits features consistent with desquamative gingivitis.

Wegener's granulomatosis affecting the gingi-val tissues. The classic "strawberry gums" appearance of the mandibular gingiva is seen in this patient. A slight resemblance with desquamative gingivitis is evident.

Erythema multiforme. Large, shallow, and painful ulcers involving the labial and buccal mucosae. Hemorrhagic crusting of the mandibular vermilion border of the lips is observed.

Treatment of lichen planus.

 Treatment of pemphigus vulgaris.

Treatment of cicatricial pemphigoid.